Provider Demographics
NPI:1720153257
Name:BOGARD, RANDY J (DMD, MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:J
Last Name:BOGARD
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-5021
Mailing Address - Country:US
Mailing Address - Phone:360-653-1114
Mailing Address - Fax:360-653-5509
Practice Address - Street 1:1809 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-5021
Practice Address - Country:US
Practice Address - Phone:360-653-1114
Practice Address - Fax:360-653-5509
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030185191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery